Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules

XIII. CAQH CORE 259: AAA Error Code Reporting Rule

1. Can a health plan/information source return a AAA error segment that contains only the first error condition detected or must they return as many AAA segments as there are errors in the X12 270?

A health plan/information source is required to return a AAA segment for each error condition that it detects in a X12 270 request, as described in sections 4.3-4.5 of the rule.

2. Is the receiver of the X12 271 response expected to be able to detect all AAA segment error conditions reported by the vendor/health plan and display them to an end user?

Yes, the receiver of the X12 271 response, i.e., the system that originated the X12 270 inquiry, is required to detect all combinations of error conditions from the AAA segments in the X12 271 responses, as defined in Table 4.5-1 Error Reporting Codes & Requirements, and to display to the receiving system’s end user text that uniquely describes the specific error condition(s) and data elements returned by the health plan in the X12 271 response.

3. When a health plan’s search criteria detects errors during its subscriber/dependent verification editing process, does the CAQH CORE 259: AAA Error Reporting Rule specify in what loop (subscriber or dependent) the error should be reported?

CAQH CORE 259: AAA Error Code Reporting Rule Version 2.1.0 identifies 17 error conditions, some of which may occur in the subscriber loop and others which may occur in the dependent loop. Section 4.4 of the CAQH CORE 259 Rule states that “when a health plan detects any of the specified error conditions it must return an appropriate AAA segment for each error detected and return other data elements as specified.” Thus, the health plan would determine the loop in which to return the appropriate AAA error codes required by the CAQH CORE Rule.

4. Does the CAQH CORE 259: AAA Error Code Reporting Rule require a health plan to validate DOB?

No, this CAQH CORE Rule does not require a health plan (or information source) to validate a DOB; however, when a DOB is validated and errors are found, the receiver of the X12 270 inquiry is required to return an X12 271 response as specified in the rule.

5. Does the CAQH CORE 259: AAA Error Code Reporting Rule require that entities use specific AAA03 error codes for specific errors?

Yes, the rule specifically identifies the AAA03 error codes that must be returned for each error condition, which may occur in either or both of the Subscriber or Dependent loops (refer to Rule Section 4.5 and the Error Reporting Codes & Requirements Table).

6. Does this rule require specific search or match criteria logic to be used when validating member demographic data?

No, the CAQH CORE 259: AAA Error Code Reporting Rule does not require a health plan/information source to use any specific search and match criteria or logic.

7. Is a health plan or information source required to return an X12 271 response with the specified AAA error codes for each test script for the CAQH CORE 259: AAA Error Code Reporting Rule specified in the CORE Certification test suite?

No. Due to the variability in search and match logic and the data elements used by health plans and information sources, some health plans and information sources may actually match the member in the X12 270 Inquiry test case rather than return the expected AAA error code in the X12 271 Response. An entity seeking CORE Certification can successfully pass the test for this rule by generating at least one X12 271 Response with an AAA Error Code for at least one of the certification test scripts.

8. How does a health plan identify the correct error condition description to return when multiple error conditions are mapped to the same code?

CAQH CORE 259 Rule, Section 3.1, What the Rule Applies To, notes that the rule defines a standard way to report errors that prevent health plans (or information sources) from responding with the eligibility information for the requested patient or subscriber. The rule requires use of a unique error code, wherever possible, for a given error condition so that the re-use of the same error code is minimized. Where this is not possible, the goal (when re-using an error code) is to return a unique combination of one or more AAA segments along with one or more of the submitted patient identifying data elements such that the provider will be able to determine as precisely as possible what data elements are in error and take the appropriate corrective action. The CAQH CORE Rule does not require error condition descriptions to be returned.

9. What must the receiver of the X12 271 display when receiving multiple AAA error codes?

CAQH CORE 259 Rule, Section 4.2, Basic Requirements for Receivers of the v5010 271, identifies basic requirements for the “receiver” of the X12 271 response. These requirements include that the “receiver” must “display to the end user text that uniquely describes the specific error condition(s) and data elements returned by the health plan in the v5010 271”. The receiver may exercise discretion regarding the actual text to be displayed as long as the wording of the text displayed accurately represents the AAA03 error code and the corresponding Error Condition Description without changing the meaning and intent of the error condition description.